Primary prevention of cardiovascular disease: new guidelines, technologies and therapies.

A trend in primary prevention of cardiovascular disease (CVD) has been a move away from managing isolated risk factors, such as hypertension and dyslipidaemia, towards assessment and management of absolute CVD risk.

In Australian guidelines, absolute CVD risk is calculated as the probability of a stroke, transient ischaemic attack, myocardial infarction, angina, peripheral arterial disease or heart failure occurring within the next 5 years.

For patients currently taking a blood pressure (BP)-lowering or lipid-lowering agent, pretreatment values should be used to calculate risk.

Patients at high absolute risk of CVD (> 15% over 5 years) should be treated with both BP-lowering and lipid-lowering agents, unless contraindicated or clinically inappropriate.

For patients at moderate absolute risk of CVD (10%–15%) treatment with a BP-lowering and/or a lipid-lowering agent should be considered if the risk remains elevated after lifestyle interventions, BP is ≥ 160/100 mmHg, there is a family history of premature CVD, or the patient is of South Asian, Middle Eastern, Maori, Pacific Islander, Aboriginal or Torres Strait Islander ethnicity.

BP measurements taken using an oscillometric device can be used to approximate mean daytime ambulatory BP.

Conclusion

The move to an approach based on absolute risk for the primary prevention of CVD is likely to improve the effectiveness and cost-effectiveness of treatment, and the 2009 and 2012 NVDPA guidelines support this approach. The absolute risk approach targets the patients who are most likely to benefit from medication, and reduces the medicalisation of patients at low risk. The increasing availability of cardiovascular risk calculators, either on the internet or as standalone software, also removes one of the barriers to implementing the absolute risk approach. New technologies have varying evidence of utility, but oscillometric BP devices can be readily adopted. The role of coronary artery calcium scoring and other biomarkers in risk stratification is yet to be established.